Bloodborne

Pathogens Exposure

Control Plan Northern Illinois University Environmental Health and Safety Updated 6/6/19

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Review and Updates

Date Reviewed by Changes Made

February 4, 2015 Dave Scharenberg Contact information

February 24, 2016 Dave Scharenberg

Remove Kish. Corp.

Health, add Physicians

Immediate Care. Update

contact information.

October 6, 2017 Dave Scharenberg Annual Review

June 6, 2019 Dave Scharenberg Annual Review

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Contents

Introduction ............................................................................................................................................... 4

Program Administration ............................................................................................................................ 4

Employee Exposure Determination ........................................................................................................... 5

Methods of Implementation and Control .................................................................................................. 5

Universal Precautions ............................................................................................................................ 5

Exposure Control Plan ........................................................................................................................... 6

Engineering Controls and Work Practices ............................................................................................. 6

Personal Protective Equipment (PPE) ................................................................................................... 7

Work Practices ....................................................................................................................................... 9

Hepatitis B Vaccine ................................................................................................................................. 12

General ................................................................................................................................................. 12

Hepatitis B Vaccination Procedure ...................................................................................................... 12

Post-Exposure Evaluation and Follow-up ............................................................................................... 13

Administration of Post-Exposure Evaluation and Follow-Up ................................................................. 14

Evaluation of Exposure Incident ............................................................................................................. 15

Employee Training .................................................................................................................................. 15

Recordkeeping ......................................................................................................................................... 16

Training Records ................................................................................................................................. 16

Medical Records .................................................................................................................................. 17

OSHA Recordkeeping ......................................................................................................................... 17

Sharps Injury Log ................................................................................................................................ 17

Department Listings and Contact Information ........................................................................................ 19

Job Classifications: .................................................................................................................................. 20

Used Needle Disposal Program ............................................................................................................... 21

Biohazard Label ...................................................................................................................................... 22

Hepatits B Vaccine Declination ............................................................................................................. 23

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Introduction

Northern Illinois University (NIU) will make every reasonable effort to provide a work

and academic environment that is free from significant health hazards for the University

community. In pursuit of this endeavor the following Exposure Control Plan (ECP) is

provided to eliminate or minimize occupational exposure to bloodborne pathogens in

accordance with OSHA standard 29 CFR 1910.1030, “Occupational Exposure to

Bloodborne Pathogens.”

This Exposure Control Plan (ECP) is a key document in implementing and ensuring compliance

with the standard, thereby protecting our employees. This ECP includes:

1) Determination of employee exposure.

2) Implementation of various methods of exposure control, including:

a. Universal precautions

b. Engineering and work practice controls

c. Personal protective equipment

d. Housekeeping

3) Hepatitis B vaccination.

4) Post-exposure evaluation and follow-up.

5) Communication of hazards to employees and training.

6) Recordkeeping.

7) Procedures for evaluating circumstances surrounding an exposure incident.

The methods of implementation of these elements of the standard are discussed in the

subsequent pages of this ECP.

Program Administration

The Department of Environmental Health and Safety (EHS) is responsible for the

implementation of the ECP. EHS will maintain, review and update the ECP at least

annually, and whenever necessary to include new or modified tasks and procedures.

Contact: Dave Scharenberg, 815-753-1093 for Facilities related departments

Michele Crase, 815-753-9251 for Academic related departments

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Those employees whose job classifications are determined to have occupational exposure

to blood or Other Potentially Infectious Material (OPIM) must comply with the

procedures and work practices outlined in this ECP.

Each NIU Department that has employees who are potentially exposed to bloodborne

pathogens will maintain and provide all necessary personal protective equipment (PPE),

engineering controls (e.g., sharps containers), labels and biohazard bags as required by

the standard. They will also ensure that adequate supplies of the aforementioned

equipment are available in the appropriate sizes. See Appendix A for departmental

listings of contact information.

The Physician or other Licensed Health Care Provider (PLHCP) will maintain and

provide copies of the employee’s medical record directly to the employee upon the

employee’s request. The employee also has the right to complete an “Authorization to

Release Medical Records” form so the PLHCP can send the employee’s medical records

to the employee’s primary care physician

Contact information:

Physicians Immediate Care, 2496 DeKalb Avenue, Sycamore IL, 60178

815-754-1122

EHS will provide training to departments/individuals upon request. Each department is

responsible for ensuring its employees are current on their training.

Contact: Dave Scharenberg, 815-753-1093.

Employee Exposure Determination

Occupational Exposure is defined as reasonably anticipated skin, eye, mucous membrane,

or parenteral contact with blood or other potentially infectious material (OPIM) that may

result from the performance of an employee’s duties.

Job classifications and associated tasks in which certain employees may have

occupational exposure are listed by department in Appendix B.

Methods of Implementation and Control

Universal Precautions

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Universal precautions will be observed at Northern Illinois University in order to prevent

contact with blood or OPIM. Universal precautions means that all blood and OPIM will

be considered infectious regardless of the perceived status of the source individual.

OPIM is defined as amniotic fluid, pericardial fluid, pleural fluid, synovial fluid,

cerebrospinal fluid, semen and vaginal secretions, or any body fluid visibly contaminated

with blood.

Exposure Control Plan

Employees covered by the bloodborne pathogens standard will receive an explanation of

this ECP during their initial training session. It will also be reviewed in their annual

refresher training. All employees have an opportunity to review this plan at any time

during their work shifts by contacting the Department of Environmental Health and

Safety. If requested, EHS will provide an employee with a copy of the NIU ECP free of

charge within 15 days of the request. In addition, the plan will be available on the EHS

website at www.ehs.niu.edu.

EHS is responsible for reviewing and updating the ECP annually, or more frequently if

necessary to reflect any new or modified tasks and procedures, which affect occupational

exposure, and to reflect new or revised employee positions with occupational exposure.

Engineering Controls and Work Practices

Engineering controls and work practice controls will be used to prevent or minimize

exposure to bloodborne pathogens. The specific engineering controls and work practice

controls used are listed below.

Control Location

Sharps containers Health Services exam rooms, laboratory

areas which use needle devices, some

athletic rooms and student recreation

facilities, EHS

Biohazard disposal bags Health Services exam rooms, laboratory

areas that use biological material including

rDNA, athletic trainer rooms, student

recreation facilities, EHS

Blood spill cleanup kit EHS, Building Services

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Sharps disposal containers are inspected and maintained or replaced by the individual

responsible for the exam rooms, laboratories (Responsible Researcher) or athletic trainer

rooms (Athletic Department), Student Recreation facilities (Director of Student

Recreation). The sharps disposal containers are checked on an ongoing basis by the

responsible department or individual and are replaced when necessary to prevent

overfilling.

Students, faculty, and staff are encouraged to properly dispose of sharps. Sharps

containers are available at EHS. Fliers about the Needle Disposal Program are

distributed to new students, posted in various locations (including residence halls)., Used

containers will be collected by EHS and properly disposed of within the university

Biowaste Program (see Appendix C).

The university identifies the need for changes in engineering control and work practices

through EHS review of the Supervisor’s Report of Injury or Illnesses form, Employee

First Report of Injury Illinois Form 45, employee interviews, or consultation with each

department.

Evaluation of new procedures or new products used by each department will include a

literature review, information from the supplier and written evaluation of all products

considered.

Each Department Chair or Director is responsible for effective implementation of these

recommendations. Contact the Department of Environmental Health and Safety for

assistance on this matter.

Personal Protective Equipment (PPE)

Personal protective equipment is provided to NIU employees at no cost to them.

Training is provided by the supervisor in the use of the appropriate PPE for the tasks or

procedures employees will perform.

The types of PPE available to employees are dependent on the jobs they perform. Some

examples of PPE are gloves, lab coat or apron, and eye protection.

Necessary PPE is located within each department and may be obtained through the

employee’s supervisor. If a problem arises in obtaining proper PPE, please contact EHS.

All employees using PPE must observe the following precautions:

1. Wash hands immediately or as soon as feasible after removal of gloves or other PPE.

2. Remove PPE after it becomes contaminated, and before leaving the work area.

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o Used PPE may be disposed of in a biohazard bag or appropriately labeled laundry

bag.

o Wear appropriate gloves when it can be reasonably anticipated that there may be

hand contact with blood or OPIM, and when handling or touching contaminated

items or surfaces; replace gloves if torn, punctured, contaminated, or if their

ability to function as a barrier is compromised.

o Utility gloves may be decontaminated for reuse if their integrity is not

compromised; discard utility gloves if they show signs of cracking, peeling,

tearing, puncturing, or deterioration.

3. Never wash or decontaminate disposable gloves for reuse.

o Wear appropriate face and eye protection when splashes, sprays, spatters, or

droplets of blood or OPIM pose a hazard to the eye, nose, or mouth.

o Remove immediately or as soon as feasible any garment contaminated by blood

or OPIM. Remove in such a way as to avoid contact with the outer surface.

The procedure for handling used PPE is as follows:

Gloves

Gloves should be removed by grasping the outside wrist area of one glove using

the other gloved hand. Take care not to touch skin or clothing with contaminated

gloves. Pull the grasped glove inside out and hold onto it with the remaining

gloved hand. Take the ungloved hand reach inside the wrist part of the remaining

glove. Pull the remaining glove inside out. In this way the gloves should be one

inside the other and the contaminated surfaces wrapped inside. Place

contaminated gloves into the biohazard bag provided.

Utility gloves may be decontaminated with ten percent solution of freshly

prepared bleach or an EPA approved disinfectant. However, utility gloves must

be discarded if they are cracked, peeling, torn, punctured, or exhibit other signs of

deterioration, or when their ability to function as a barrier is compromised.

Eye and Face Protection

Masks in combination with eye protection devices, such as goggle or glasses with

solid side shields, or chin-length face shields, are to be decontaminated with a ten

percent solution of freshly prepared bleach or an EPA approved disinfectant and

replaced in the storage areas.

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Gowns/Aprons

Gowns or aprons, which are impervious to fluids, shall be worn when sorting and

washing contaminated laundry. Disposable gowns or aprons, if used, are not to be

washed or decontaminated for re-use and are to be replaced as soon as they are

torn, punctured, or when their ability to function as a barrier is compromised.

Place contaminated gowns/aprons into the biohazard bag provided.

Work Practices

Sharps Containers

Sharp items such as broken glassware, knives, needles, or similar material that

may be contaminated shall be discarded immediately or as soon as feasible. Do

not pick up sharp items directly with the hands. Sweep or brush the material into

a dustpan and dispose of it in a sharps container. All sharps containers shall be

closable, puncture-resistant, leak-proof on sides and bottom, and labeled with a

biohazard label or red in color. Containers shall be maintained upright throughout

use and replaced routinely or when two-thirds full.

Sharps disposal containers may be purchased by responsible departments. Sharps

containers must be located in exam rooms, labs, and other areas where sharps are

used on a regular basis so they are easily accessible and as close as feasible to the

immediate area where sharps are used.

Once a sharps container is two-thirds full the lid is closed and the container is

placed in a lined Biohazard box. The boxes are collected and properly disposed

of by an outside contractor. Manifests of all pickups are available at

Environmental Health and Safety.

Other Regulated Waste

Blood, OPIM, and recombinant DNA waste shall be placed in containers that are

closeable, constructed to contain all contents and prevent leakage of fluids during

handling, storage, transportation or shipping.

The container must be lined with a biohazard disposable bag. Biohazard

disposable bags shall be closable and leak proof. The container and bag will be

either red or red-orange in color or have a biohazard label affixed to it. The

container must be closed before removal to prevent spillage or protrusion of

contents during handling, storage, transport.

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The container is transported to the nearest biohazard waste box. The bag insert is

tied closed and placed in the box. The boxes are collected and properly disposed

of by an outside contractor. Manifests of all pickups are available at

Environmental Health and Safety.

NOTE: Disposal of all PIMW shall be in accordance with applicable federal,

state and local regulations. Check with the Department of Environmental Health

and Safety for more information on disposal regulations.

Hand Washing Facilities

Hand washing facilities are available to the employees who incur exposure to

blood or OPIM. OSHA requires that these facilities be readily accessible after

incurring exposure.

Contaminated Equipment and Work Surfaces

The manager, supervisor, or designee on duty is responsible for ensuring that

equipment which has become contaminated with blood or OPIM shall be

decontaminated as necessary, unless the decontamination of the equipment is not

feasible.

All contaminated surfaces will be decontaminated as soon as feasible after any

spill of blood or OPIM, as well as the end of the work shift if the surface may

have become contaminated since the last cleaning.

Decontamination can be accomplished using a ten percent solution of household

bleach, or other EPA approved disinfectant.

Regulated waste is placed in containers which are closable, constructed to contain

all contents and prevent leakage, appropriately labeled or color-coded (see

Labels), and closed prior to removal to prevent spillage or protrusion of contents

during handling.

Laundry Procedures

University Recreation Services may have gym towels that are potentially

contaminated. These towels will be laundered at the Recreation Services.

Laundry Handling Procedures – Recreation Services:

a. Minimize personal contact with the laundry.

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b. Put on an apron and vinyl or latex gloves prior to coming into contact with the

dirty laundry.

c. Agitate laundry as little as possible when removing it from the designated bins.

d. Follow instructions posted on the dryer for doing the laundry. This includes the

use of bleach. Place the apron in with the soiled laundry after you have placed all

of the laundry in the washer.

e. Spray all containers and surfaces that have come into contact with soiled laundry

with the bleach solution bottle. You must make up a fresh solution daily.

Instructions will be found on the spray bottle.

f. When removing the gloves, follow the appropriate procedure as recommended in

your first aid training so as to not come into contact with the exterior surface of

the gloves.

g. Dispose of the vinyl or latex gloves in the hazardous material bin located in the

key closet.

h. Wash your hands immediately each time you do the laundry and when you come

into contact with surfaces that soiled laundry may touch.

The Department of Public Safety has a cleaning service for their uniforms. When the uniforms

are contaminated with blood or OPIM, the contaminated laundry is placed in a bag that is

properly labeled or color-coded. This alerts the cleaners to use proper precautions when cleaning

the garment.

Labels

All biohazard containers must have a biohazard label and/or be color coded red or

red-orange, this includes specimen transporters, waste containers, laundry bags

containing contaminated materials, and sharps containers. Employees are to

notify EHS, if they discover regulated waste containers, refrigerators containing

blood or OPIM, contaminated equipment, etc., without proper labels. (See

Appendix D for an example of the biohazard label.)

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Hepatitis B Vaccine

General

The University makes available the Hepatitis B vaccine to all employees who have

potential occupational exposure. A post-exposure follow-up will be given to employees

who have had an exposure incident.

The University shall ensure that all medical evaluations and procedures for the Hepatitis

B vaccine and post-exposure follow-up, including protective measures are:

1. Made available at no cost to the employee.

2. Made available to the employee while on duty, at a reasonable time and place.

3. Performed by/under the supervision of a licensed physician or by/under the

supervision of another licensed health care professional (PLHCP).

4. Provided according to the recommendations of the U.S. Centers for Disease Control

and Prevention.

An accredited laboratory shall conduct all laboratory tests at no cost to the employee.

Hepatitis B Vaccination Procedure

Physician’s Immediate Care (PIC), in cooperation with Environmental Health and Safety,

are responsible for the Hepatitis B Vaccination Program.

The Department of Environmental Health and Safety will provide training to employees

on Hepatitis B vaccinations, addressing the safety, benefits, efficacy, methods of

administration, and availability.

The hepatitis B vaccination series is available at no cost, after training and within 10 days

of initial assignment, to employees identified in the exposure determination section of

this plan. Vaccination is encouraged except when:

Documentation exists that the employee has previously received the series.

1. Antibody testing reveals that the employee is immune.

2. Medical evaluation shows that vaccination is contraindicated.

However, if an employee chooses to decline vaccination, the employee must sign a

declination form (See Appendix E). Employees who decline may request and obtain the

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vaccination at a later date at no cost. Documentation of refusal of the vaccination is kept

in the employee’s department personnel file.

Post-Exposure Evaluation and Follow-up

Should an exposure incident occur contact Dave Scharenberg at 815-753-1093. Give the

name of the employee, department, supervisor, and supervisor’s phone number. If during

off hours leave a message. In addition, the supervisor will obtain a Workers’

Compensation packet. The employee will fill out the Employee’s Notice of Injury. The

supervisor must complete the Supervisor’s Report of Injury or Illness.

NIU will provide transportation, in a timely manner, for a medical evaluation. Physicians

Immediate Care will conduct an immediately available confidential medical evaluation

and follow-up. Their hours of operation are Monday – Friday 8:00 am to 8:00 pm,

Saturday and Sunday 8:00 am to 5:00 pm. During off hours the initial treatment will be

done by Kishwaukee Community Hospital Emergency Department. Follow-up will be

done by Physicians Immediate Care.

Physicians Immediate Care

2496 DeKalb Avenue

Sycamore, IL 60178

815-754-1122

Kishwaukee Community Hospital

One Kish Hospital Drive

DeKalb, IL 60115

815-756-1521

Following the initial first aid (clean the wound, flush eyes or other mucous membrane,

etc.), the following activities will be performed:

1. Document the routes of exposure and how the exposure occurred.

2. Identify and document the source individual (unless the employer can establish

that the identification is infeasible or prohibited by state law).

3. Obtain consent and make arrangements to have the source individual tested as

soon as possible to determine HIV, HCV and HBV infectivity; document that the

source individual’s test results were conveyed to the employee’s health care

provider. Specimen for testing can be brought to Physicians Immediate Care with

the employee.

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4. If the source individual is already known to be HIV, HCV and/or HBV positive,

new testing need not be performed.

5. Assure that the exposed employee is provided with the source individual’s test

results and with information about applicable disclosure laws and regulations

concerning the identity and infectious status of the source individual (e.g., laws

protecting confidentiality).

6. After obtaining consent, collect exposed employee’s blood as soon as feasible

after exposure incident, and test blood for HBV and HIV serological status.

7. If the employee does not give consent for HIV serological testing during

collection of blood for baseline testing, preserve the baseline blood sample for at

least 90 days; if the exposed employee elects to have the baseline sample tested

during this waiting period, perform testing as soon as feasible.

Administration of Post-Exposure Evaluation and Follow-Up

The Department of Environmental Health and Safety ensures that health care

professional(s) responsible for employee’s hepatitis B vaccination and post exposure

evaluation and follow-up are given a copy of OSHA’s Bloodborne pathogens standard.

The Department of Environmental Health and Safety, in cooperation with the employee’s

supervisor, ensures that the health care professional evaluating an employee after an

exposure incident receives the following:

1. A description of the employee’s job duties relevant to the exposure incident.

2. Route(s) of exposure.

3. Circumstances of exposure.

4. If possible, source individual’s blood test results. *

5. Relevant employee medical records, including vaccination status. *

*HIPPA regulations may apply.

Physicians Immediate Care provides the employee with a copy of the evaluating health

care professional’s written opinion within 15 days after completion of the evaluation.

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Evaluation of Exposure Incident

The Department of Environmental Health and Safety will review the circumstances of all

exposure incidents to determine:

1. Engineering controls in use at the time.

2. Work practices followed.

3. A description of the device being used at time of exposure (including type and

brand).

4. Protective equipment or clothing that was used at the time of the exposure

incident (gloves, eye shields, etc.).

5. Location of the incident (HS, Public Safety, Athletics’, etc.).

6. Procedure being performed when the incident occurred.

7. Employee’s training.

The Department of Environmental Health and Safety will record all percutaneous injuries

from contaminated sharps in the Sharps Injury Log.

If it is determined that revisions need to be made, the Department of Environmental

Health and Safety will work with the specific department to ensure that appropriate

changes are made to this program. (Changes may include an evaluation of safety devices,

adding employees to the exposure determination list, etc.)

Employee Training

All employees who have occupational exposure to blood borne pathogens receive

training conducted by the Department of Environmental Health and Safety or a qualified

person within their own department.

All employees who have occupational exposure to blood borne pathogens receive

training on the epidemiology symptoms and transmission of blood borne pathogen

diseases. In addition, the training program covers, at a minimum, the following elements:

1. A copy and explanation of the standard.

2. An explanation of NIU’s ECP and how to obtain a copy.

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3. An explanation of methods to recognize tasks and other activities that may

involve exposure to blood and OPIM, including what constitutes an exposure

incident.

4. An explanation of the use and limitations of engineering controls, work practices,

and PPE.

5. An explanation of the types, uses, location, removal, handling, decontamination,

and disposal of PPE.

6. An explanation of the basis for PPE selection.

7. Information on the hepatitis B vaccine, including information on its efficacy,

safety, method of administration, the benefits of being vaccinated and that the

vaccine will be offered free of charge.

8. Information on the appropriate actions to take and persons to contact in an

emergency involving blood or OPIM.

9. An explanation of the procedure to follow if an exposure incident occurs,

including the method of reporting the incident and the medical follow-up that will

be made available.

10. Information on the post-exposure evaluation and follow-up that the employer is

required to provide for the employee following an exposure incident.

11. An explanation of the signs and labels and/or color-coding required by the

standard and used at NIU.

12. An opportunity for interactive questions and answers with the person conducting

the training session.

Training materials for this facility are available at the Department of Environmental Health and

Safety.

Recordkeeping

Training Records

Training records are completed for each employee upon completion of training.

These documents will be kept for at least three years at the employee’s Department

and the Department of Environmental Health and Safety.

The training records include:

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1. The dates of the training sessions.

2. The contents or a summary of the training sessions.

3. The names and qualifications of the persons conducting the training.

4. The names and job titles of all persons attending the training sessions.

Employee training records are provided upon request to the employee or the

employee’s authorized representative within 15 working days. Such requests should

be addressed to the employee’s department or the Department of Environmental

Health and Safety.

Medical Records

Medical records are maintained for each employee with occupational exposure in

accordance with 29 CFR 1910.1020, “Access to Employee Exposure and Medical

Records.”

For the time period up to December 31, 2004, the records are maintained at NIU

Health Services. From January 1, 2005 until December 31, 2015 records are

maintained at Midwest Orthopedic Institute (Kishwaukee Corporate Medical).

Records created after January 1, 2016 will be on file with Physicians Immediate Care.

These confidential records are kept for at least the duration of employment plus 30

years.

Employee medical records are provided upon the request of the employee or to

anyone having written consent of the employee, within 15 working days. Such

requests should be sent to the Department of Environmental Health and Safety,

Northern Illinois University, DeKalb IL 60115.

OSHA Recordkeeping

An exposure incident is evaluated to determine if the case meets OSHA’s

Recordkeeping Requirements (29 CFR 1904). This determination and the recording

activities are done by Human Resource Services, Assistant Manager.

Sharps Injury Log

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In addition to the 29 CFR 1904 Recording keeping requirements, all percutaneous

injuries from contaminated sharps are also recorded in the Sharps Injury Log. All

incidences must include at least:

1. The date of the injury.

2. The type and brand of the device involved.

3. The department or work area where the incident occurred.

4. An explanation of how the incident occurred.

This log is reviewed at least annually as part of the annual evaluation of the program,

and is maintained for at least five years following the end of the calendar year that it

covers.

If a copy is requested by anyone, the copy must have all personal identifiers removed

from the report.

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Appendix A

Department Listings and Contact Information

Department Contact Telephone

Athletic Training Head Trainer, Phil Voorhis 815-753-0211

Biology Chair, Barrie Bode 815-753-0433

Building Services Tammie Pulak

Rich Carter

815-753-1147

815-753-1147

Campus Child Care Kristin Schulz 815-753-0125

Chemistry and

Biochemistry

Chair, Ralph Wheeler 815-753-1181

Medical Laboratory

Sciences

Coordinator, Ellen Olsen 815-753-6300

NIU Health Services Director, Andrew Digate 815-753-9766

Dept. of Public Safety Donald Rodman 815-753-1212

School of Nursing Chair, Nancy Valentine 815-753-1231

Recreation Services Director, David Lochbaum 815-753-9420

Lorado Taft Director, Melanie Costello 815-753-0205

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Appendix B

Job Classifications: All Employees Have Occupational Exposure

Job Title Department

See department specific

information NIU Public Safety

See department specific

information Athletics

See department specific

information Lab Schools

Job Classifications: Some Employees Have Occupational Exposure

Job Title Department

See department specific

information Building Services

See department specific

information Grounds

See department specific

information Lorado Taft

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Appendix C

Sharps Program Flier

Used Needle Disposal Program

Department of Environmental Health and Safety

Plastic containers for disposal of used syringes and needles are available at Environmental

Health and Safety for use by STUDENTS.

Those students who are diabetic or otherwise using syringes and needles for medical purposes

are invited to call Dave Scharenberg at 815-753-1093. The needle container and the disposal of

full containers is free to students. There are no forms to fill out and no personal information

needs to be given to receive the containers.

The purpose of this program is to provide a safe means for students to dispose of used medical

syringes.

Dave Scharenberg 815-753-1093

dscharenberg@niu.edu

Environmental Health and Safety

Northern Illinois University

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Appendix D

Biohazard Label

BIOHAZARD

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Appendix E

HEPATITS B VACCINE DECLINATION (MANDATORY)

I understand that due to my occupational exposure to blood or other potentially infectious

material I may be at risk of acquiring hepatitis B virus (HBV) infection. I have been given the

opportunity to be vaccinated with hepatitis B vaccine, at no charge to myself. However, I

decline hepatitis B vaccination at this time. I understand that by declining this vaccine, I

continue to be at risk of acquiring hepatic B, a serious disease. If in the future I continue to have

occupational exposure to blood or other potentially infectious materials and I want to be

vaccinated with hepatitis B vaccine, I can receive the vaccination series at no charge to me.

Signed: ____________________________________________

Date: _____________________________________